APPENDIX 1: SEIPS SYSTEMS-BASED CLASSIFICATION SCHEME FOR SAFETY THREATS AND RESILIENCE SUPPORTS IN LAPAROSCOPIC SURGERY FRAMEWORK AND THEIR OBSERVED FREQUENCY
Safety threats
PERSON
Sub-category Code Description Observed
Frequency
Unsafe Acts
Active attention failure Clinical team member is not actively listening/paying
attention/observing aspects of surgical case when they should be 44 Memory error Error/mistake due to forgetting information/steps, unintentional
omission of necessary steps, or inaccurate recall 1 Perception/comprehens ion
error
Perception/comprehension errors, or errors arising from impaired ability to accurately perceive/comprehend current system state 2 Substandard
skill/technique error
Suboptimal/non-standardized technique, approach to task execution is atypical/diverges from the standardized/optimal method; errors related to inadequate skill/experience
77 Protocol violation Clinician knowingly violates standard protocol/safe operating
procedure or fails to take necessary precautions/steps (Ex.
Participation of observer in OR processes, prioritizing personal tasks)
47
Suboptimal Clinician Condition
Lack of situation awareness
Clinician does not appropriately perceive/comprehend current
system state, unusual/unsafe circumstances, or deviation/error 7 Suboptimal mental
state Ex. Anger, frustration, arrogance, complacency 0
Suboptimal
physiological condition Ex. Hunger, fatigue 0
Inadequate Experience/
Knowledge
Insufficient task experience/knowledge
Individual lacks experience to execute the task
correctly/safely/efficiently (potential to contribute to error) 3 Insufficient tool
experience/knowledge
Individual lacks experience to correctly/safely/efficiently operate or handle surgical tool (potential to contribute to error) 3 Leadership Failures
Failure to explore concerns Clinician in leadership position does not adequately
address/explore concerns raised by co-worker 1
Failure to guide/supervise
Absence of supervision over less experienced team members at
a critical point in time 4
Team Effectiveness Issues
Personnel late Clinical team member arrives late to the OR 3
Suboptimal team dynamics
Evidence of incompatibility/discord between team members as a result of personality differences, unfamiliar team, etc. 0 Unnecessary
conversation
Clinical team members engage in trivial or unnecessary conversation
that is not relevant to the task at hand 1
Communication Failures
Communication unclear
Communication between healthcare professionals is not delivered clearly/adequately/effectively, not communicating with teammate directly, etc.
3 Communication absent Complete absence of team communication when communication is
critical, leading to confusion/disrupted workflow 13 Communication delay Delay in essential communication (Ex. Surgical team fails to
communicate care plan changes to other team members in timely manner)
2 TASKS
Sub-category Code Description Observed
Frequency Suboptimal Task
Demands/ Workload
Bad ergonomics Task is physically demanding (Ex. Strenuous, heavy, poor
ergonomics associated with task, bad angles) 4
Cognitively demanding Characteristics/complexity/difficulty of task which have the potential to increase the cognitive workload of the clinician 0
Time pressure Time pressure associated with task 0
Overwhelming workload High workload experienced due to high number of required tasks, not enough colleagues, unanticipated additional responsibilities etc.
0 Unstimulating task Clinicians express boredom with task at hand/lack of mental
stimulation 0
Unexpected task complication
Ex. Error/issue/complication on anaesthesia side temporarily
delays surgical case progression 1
Preventable Secondary Tasks
Diversion, personnel issue
Clinician required to attend to secondary task that diverts attention from primary objective task/delays the completion of another task; diverts attention, interrupts action, Ex. Correcting form of inexperienced scrub nurse
1
Diversion, tool/tech issue
Clinician required to attend to secondary task that diverts attention from primary objective task/delays the completion of another task; diverts attention, interrupts action; Ex.
Troubleshooting malfunction
1
Diversion, workspace issue Clinician required to attend to secondary task that diverts attention from primary objective task/delays the completion of another task; diverts attention, interrupts action; Ex.
Rearranging obtrusive equipment
0
Diversion, organization/
management
Clinician required to attend to secondary task that diverts attention from primary objective task/delays the completion of another task; diverts attention, interrupts action; Ex. Managing scheduling issues
2
Patient-Related Challenges
Patient complexity Unique patient factors (ex. Implant, pacemaker) add extra layer of complexity to case (known prior to surgery initiation) 0 Challenging patient
management
Clinicians express difficulty in managing the patient throughout
the case (Ex. airway) 5
Challenging anatomy Physical/anatomical characteristics of the patient that may exacerbate the difficulty of a task (potentially unknown to team until surgery is underway)
0
Disruptions
Unnecessary verbal interruption
Communication delivered to an operating surgeon/working clinician (inappropriate timing); engaging a preoccupied clinician in an unnecessary discussion
2
Other case interruption
Another case requires attention of clinical team, draws attention away from present case (Ex. Clinician must leave to attend another OR); Clinicians discuss details of another patient
2 TOOLS AND TECHNOLOGY
Sub-category Code Description Observed
Frequency Lack of Familiarity
Unfamiliar configuration/setup
Tool/instrument/tech configured in a way that is
unusual/unfamiliar to user 0
Unfamiliar tool Clinicians are using a tool/instrument/equipment that is
different from their usual tool/is new/is unfamiliar 2
Substandard Functionality/ Utility
Malfunction Unanticipated malfunction/failure of tool/equipment during
use (Ex. stapler, grasper, camera, monitor) 8
Assembly failure A multi-part tool/instrument comes apart while in use 0 Desirable feature
missing
Laparoscopic tool/instrumentation does not possess function/feature
that would be valuable/useful to user 0
Notification system lacking
Absence of notification to user in the event of setup
error/technological malfunction/improper use 0
Unintended effects Proper use of tool results in unintended effects (Ex. Thermal spread of energy device is abnormally/unexpectedly high despite proper use/setting)
0 Dangerous design elements Elements of the tool/equipment design have the potential to
place patient safety at risk 0
Inconsistent
functionality Standard use of tool/tech produces inconsistent results 2
Safety/ Reliability Issues Not robust
Tool design does not sufficiently protected against use error;
tool/tech design allows for unintentional/accidental deployment of undesired functions; easy to mess up
6 Tool/task mismatch Available tool is incompatible with/inappropriate for the task at hand 0 Workarounds/
improvisation
Clinicians rely on workarounds to bypass usability problems/achieve
desired goals 0
Usability Issues
Tech instructions unclear
Instructions for using equipment/error messages are confusing/not
easily interpreted 0
Instrument differences
Differences/inconsistencies between the designs of the
laparoscopic instruments force users to change/adapt their surgical approach with each change in instrument
0 Unintuitive The expected/proper usage of the equipment is not made clear by
its design 0
Inefficient Equipment/tool design does not support efficient workflow/use 0 Suboptimal ergonomics Device in use is not universally ergonomic (Ex. design is biased for
ease of use by wither men or women) 2
Substandard packaging/labels
Design of tool/equipment packaging that contributes to drops/delays/issues during acquisition/opening, labelling (Ex.
Relevant/important/useful information is missing from labels on tools)
0
Inadequate Availability
Item unavailable Clinical team is unable to access/acquire required instrumentation
for the present procedure 0
Item missing Required item is not available in OR when need for it arises (Ex.
nurse must leave room to get other scope) 1
Setup/assembly issue Required tool was not ready for use when the need for it arose due
to improper setup/not plugged in etc. 0
PHYSICAL ENVIRONMENT
Sub-category Code Description Observed
Frequency
Suboptimal Workspace Setup
Unergonomic configuration
Configuration of equipment is not optimized physically for ease of use/risk of ergonomic injury (Ex. Forces awkward positioning) 8 Inefficient
configuration/
positioning
Configuration of equipment/people hinders workflow/contributes to delays (Ex. Poor placement of equipment contributes to dropped tools)
10 Non-standardized
layout Configuration of equipment does not conform to standard/expected
layout 0
Suboptimal Workspace Design
Insufficient space Physical layout of room constrains people/equipment (Ex.
Equipment in the OR impedes clinician pathways) 0 Valuable elements missing Lack of seating in work area causing clinicians to compromise and
use inappropriate equipment to rest 1
Suboptimal Ambient Conditions
Distracting workflow
sounds Unexpected noise generated by movement of equipment/door
closing etc. 2
Distracting electronic sounds
Unanticipated noise generated by electronics in the operating room that draw clinician attention away from tasks at hand 0 Distracting human
sounds
Unexpected sounds made by colleagues/individuals present in the OR that have the potential to distract from present task 0 Bad lighting Lighting in OR is not appropriate for the present task 0 Uncomfortable
temperature Suboptimal ambient temperature for worker comfort 0
ORGANIZATION
Sub-category Code Description Observed
Frequency
OR Resource Mismanagement
Inadequate resource allocation
Inadequate allocation of necessary surgical resources to surgical tool sets (Ex. Tool shortage, not enough to go around) 0 Inadequate resource
procurement
Failure to procure necessary/preferred surgical tools/materials (Ex.
Bad purchasing decisions) 0
Support services unavailable
Lack of support for troubleshooting intraoperative issues (Ex. No technical support staff available when needed) 0 Safety Culture
Deficiencies
Inadequate risk resolution Recurrent issues arising in the OR that have the potential to
compromise safety are inadequately communicated/resolved 5 Unsafe staffing Ex. Not enough staff present for current procedure; staff
present are working post-call 1
Perioperative Process Failures
Inaccurate documentation
Preoperative documentation issues, inconsistencies/errors/inaccuracies
in patient record 0
Incomplete information
Information available to clinicians is insufficient for adequate case preparation Ex. Indicators used to approximate case difficulty/potential challenges do not sufficiently reflect actual difficulty 0
Suboptimal Policies/
Procedures
No safety check No protocol mandating clinicians to check with/communicate
with team prior to execution of critical procedure step 15 No cover when absent
Extra personnel are not called upon/are not available to cover/complete/support the required tasks of a team member when absent from the OR
1 Failure to standardize Failure to standardize safety/efficiency enhancing
behaviour/procedure/protocol 16
Ineffective Staff Management
Staff change Nursing/anaesthesia/surgery shift change/new clinician joining team
while case is in progress 0
Staffing communication
failure Staffing issues/changes are inadequately communicated to OR team 0 Traffic High traffic in the OR, personnel entering/exiting excessively 0 Inadequate Provision of
Training Inadequate training
provided Lack of organizational provision of training to clinical staff 0 EXTERNAL ENVIRONMENT
Sub-category Code Description Observed
Frequency Latent External Threats Budget constraint Hospital budget constraints result in unavailability of preferred
tools/resources 0
Regulatory process Regulatory process is delaying the procurement of required/desired
equipment/instrumentation 0
Resilience supports
PERSON
Sub-category Code Description Observed
Frequency
Effective Guidance/
Instruction
Advising caution Surgical team lead guides colleagues on when to proceed
cautiously to ensure safe task execution 10
Sharing knowledge Care providers sharing relevant knowledge with one another to establish
a better understanding of the procedure/task 18
Skills coaching Teaching/training/coaching on safe/effective surgical skill or
technique 12
Teaching tool safety Guidance regarding the safe operation of tools that have the
potential to cause harm if used incorrectly 5
Advantageous
Experience Clinicians have sufficient experience with required tasks to complete them correctly/efficiently + compensate for suboptimal conditions 0 Adaptability Clinician/team exhibit adaptability in the
presence of 0
Clinician Condition dynamic/unpredictable/unideal system conditions
Good situation awareness Clinician perceives, comprehends, acknowledges and subsequently reacts to unusual circumstances/changes/deviations during procedure 16 Calm control Clinician demonstrates calm, controlled response to unexpected event
(ex. Unexpected bleeding), maintains communication and task performance
0
Anticipatory Action
Contingency planning Evidence of planning for unanticipated events + communicating
plan to team 1
Error margins Surgeon executes surgical step while preserving margin for error 0 Proactive team management Leadership regarding the delegation of tasks to clinical team members
in advance of their required completion (Ex. Surgeon tells nurse to get something in advance)
1 Proactive task completion Clinician proactively completes required task in advance of
prepare tool/resource for use by surgical team before it is needed, without being asked
11 Establishing next steps Evidence of proactive planning for subsequent surgical
tasks + communicating plan to team 7
Effective Teamwork
Collaborative decision- making
Discussion among surgeons/evaluating options prior to ultimate
decision 5
Interdisciplinary problem solving
Clinicians with different backgrounds collaborate to address a
concern that has arisen 5
Team harmony Evidence of synergy/harmony among team members (Ex. Getting along
well, enjoy working with each other) 2
Debriefing Team discussion at the end of case to evaluate surgical performance/explore concerns
6 Shared mental model Clinical team works to establish a shared mental model/shared
understanding of the patient/procedure to enable smooth/safe workflow 6
High- Performance Behaviour
Evaluating circumstances Clinician evaluates/examines the current surgical situation or state of the patient/procedure before continuing
procedure/executing step
10 Safety check Clinician checks with team before executing critical step in
procedure to ensure patient safety 6
Paying attention Supporting clinical team members diligently paying attention to
progression of surgical case; listens attentively to teammates 8
Effective technique Clinicians favour safe/effective techniques 1
Surgical quality control
Surgeon monitors and controls quality of surgical work performed,
strives for excellence in task execution 24
Effective Communication
Direct address Directly addressing colleagues so as to capture their attention when
needed 8
Communicating changes
Clinicians communicating changes in the state of the surgical system (Ex. Change of operative care plan, anaesthesia notifying when medication administered)
12 Communicating
progress
Surgery and anaesthesia communicating to ensure shared
understanding of current system state 25
Verbalize/narrate action Clinical communicates/verbalizes/describes current action with team
members during task execution 3
Task verification Clinician verifies the nature of the required task (ex. Surgical
procedure) with another clinician/the patient record 7 Detailed instructions Clear, descriptive instructions from one clinician to
another result in smooth, safe execution of task 2 Voicing concerns Clinicians are able to freely communicate case-related
concerns to colleagues 10
Positive feedback Positive feedback from experienced/leading clinician to
subordinate colleague regarding performance 1
Strong Leadership
No criticism Non-criticizing approach to error response that promotes open
communication/learning, eliminates fear of punishment 2 Checking in with team Lead surgeon checks to see how team is doing/feeling prior to
proceeding with the case 2
Encouraging open communication
Encouragement of open communication among team regarding
safety concerns/discomfort/perceived issues by team lead 1 Supervision Supervision of team and surgical progress at critical points by
individual with authority/experience 9
TASKS
Sub-category Code Description Observed
Frequency Optimal Task
Demands/ Workload
Good ergonomics Safety/efficiency facilitated through optimizing ergonomics of task (Ex.
Adjusting monitor to prevent neck strain, better port placement) 2 Relaxed pace No time pressure for task completion/ no unnecessary rushing 0 TOOLS AND TECHNOLOGY
Sub-category Code Description Observed
Frequency
Adequate Availability
Backups available Alternative tool/tech/device is available to replace a malfunctioning one
(i.e. Backups!) 0
Options available Multiple options of a given tool/resource are available for use (Ex.
Multiple scopes available to choose from) 0
Extras available More surgical instrumentation/equipment/materials than originally are available in OR/available for retrieval from reserves outside of OR 0 Preserved accessibility
Required surgical tools/equipment/materials remain accessible following completion of associated step/procedure and are available if revision required
0
Optimized Safety/Usability
Ergonomic tool Device in use is notably ergonomic, appropriate weight, optimized
for ease of use 0
Intuitive The expected use/function of surgical tool/instrumentation is made
clear by its design 0
Easily adjustable
Key equipment can be easily and quickly adjusted/re-configured for safety/ease of use (ex. Monitors can be adjusted quickly to achieve optimal viewing angle)
0 Forced functions Design-imposed constraints or forced functions (reducing risk of
misuse) 0
Effective Functionality
Tool maintained Maintenance of the tool throughout the case keeps it in optimal
working condition 1
Informative features
Surgical instrumentation/tool possesses feature that conveys important information to user (ex. Blinking lights when proper setup achieved, tactile feedback)
0 Audible alarm Critical surgical equipment produces an audible alarm to alert
the clinical team when a related error/failure/complication occurs
0 PHYSICAL ENVIRONMENT
Sub-category Code Description Observed
Frequency Optimal Workspace
Design
Spacious Configuration of OR equipment creates spacious pathways/ample space
for clinician movement 0
Workspace standardization
Design of the workspace area is standardized so as to facilitate efficiency/effective workflow (Ex. Standardized storage for intraoperative consumables)
0
Optimal Workspace Setup
Layout optimized Layout of the OR is optimized as needed; ability to move equipment around in physical space; supports efficient workflow 12 Efficient positioning Positioning of people/patient supports efficient workflow 12
Optimal Ambient Conditions
Optimal lighting Lighting in OR is appropriate for present surgical tasks 3 Quiet Peace and quiet in OR, no auditory distractions during procedural step 0 ORGANIZATION
Sub-category Code Description Observed
Frequency
Effective Training Program
In situ training
Prioritization of practical, hands-on training/teaching (procedures, techniques, etc.) of staff within the OR that does not hinder case progression
8 Trainee autonomy Less experienced surgeon is given freedom to choose which step
they feel comfortable with/want to practice 1
Asking questions Clinicians are free to ask questions/ask questions without penalty 8
Strong Safety Culture
Lessons learned Clinical team discusses previous mistakes for the purpose of
learning not to repeat them 1
Communicating mistakes
Clinicians are able to openly communicate potential
mistakes/errors to team (safety precaution) without penalty 0 User feedback Organization is receptive to user feedback concerning
improving OR activities (Ex. Preference cart update) 0
Effective Policies/
Procedures
Double check Evidence of double-check procedure for safe/effective
execution of surgical/case-related tasks 0
Timeout Clear, organized, and timely execution of a standardized timeout procedure involving all necessary clinical specialties prior to surgery commencement
18
Instrument count Nursing instrument count at the end of the case 14
Effective Resource Management
Support services available Ex. Technical support staff available to help surgical staff solve/troubleshoot equipment issues
1 User-centered resource
procurement
Decision regarding procurement of surgical
instrumentation/tools/equipment are made with input from clinical user 0 Effective Scheduling/
Staffing
Staff continuity Staff working on case do not switch/remain working for entirety of case (continuity of care/responsibility, shared understanding of case throughout)
0 Backup staff available Backup staff are available to assist/join OR team to ensure appropriate
number of staff are present 0